Using Telehealth for Clinical Teaching in Medical School During COVID-19 Times

By Leah Garfinkel Matthew, MD, Dartmouth College

Introduction

Due to the current COVID-19 pandemic, medical students are not allowed at clinical sites. Therefore, clerkship curricula in the United States must now be delivered online, while providing a similar experience. At Geisel School of Medicine at Dartmouth College in the family medicine clerkship, we provide virtual curriculum, but we wanted to find ways to involve students safely in direct patient care. Telehealth seemed like the best way to do this.

Objective

At Geisel School of Medicine at Dartmouth College, we piloted having students join the clerkship director for telehealth visits. This allowed for lessons learned and program optimization before we asked busy faculty to take this on. Next, we will roll it out to more students and faculty with the faculty in our department who are comfortable enough with telehealth to be ready to work with a student.

Methods

The two students who did a pilot were involved with every other patient on the clinical schedule. Because students cannot login to the telehealth platform on their own, they were assigned to call the patient on the phone with a precise list of tasks. Students called the patient 30 minutes ahead of time, introduced themselves, and explained that they were going to collect some background information, then the patient would be called by the attending. They performed medication reconciliation, reviewed allergies and smoking status, then took a history of present illness. They then called the attending and presented in 3-5 minutes (the attending scribed as they talked since the student note doesn't count for telemedicine) including an assessment and plan. This is an important part of making it a worthwhile learning experience for the students, and the attending let them know ahead of time that this would be expected. If running ahead of time or if the schedule was light, the student and attending would spend a few minutes discussing the assessment and plan; if not, discussion was saved for the end of the session. The attending then used the telemedicine platform to connect with the patient and asked permission for the student to join the videoconferencing call. In this pilot, all patients agreed. The attending called the student as a third party on telephone calls or used a different device if doing a video call (our video software, SBR, does not allow 3-way yet). The attending then finished the visit with the student listening in with occasional chime-in. After the visit was completed, the attending went on to the next patient while the student called the one after that. Attending and student then debriefed for 15 minutes at the end of the clinic session, including questions from the student and brief feedback from the attending.

Lessons Learned

Patients reported no concerns with this process. All of them agreed with taking the call from the medical student and also allowing the student to join the telehealth visit.

Students reported satisfaction getting backto working with actual patients (rather than the virtual cases they had been doing). They were surprised how much better the telephone format worked than what was expected.

Faculty Experience

It was surprisingly smooth and very rewarding to involve students in what is clearly a technology that is here to stay! It is something that we as attendings will use in the future and that students will need to learn.

During this process we encountered the following challenges: (1) determining the optimal patient-student-attending flow, and (2) optimal timing for delivering feedback to the learner.

Interventions to optimize the patient-student-attending flow and improve the program incude:

We will be letting patients know ahead of time that a student will be involved so they have a chance to opt out and allow for the medical student to use their time with the patient efficiently.
A Telehealth Orientation document (Appendix 1) for the students was created to simplify the process and standardize the experience for the medical students.
An orientation document for preceptors was created, “Tips/Tricks of Telehealth with Students” (Appendix 2).

All the above-mentioned interventions will make the patient-student-preceptor time go more efficiently, which will leave enough time for feedback after all the patients are seen.

Conclusions: The pilot went great. We are thrilled that we can begin to offer this opportunity more broadly to students. Similar interventions can be applied by other medical schools in need of patient contact without direct exposure. However, we expect more challenges and lessons learned, with the addition of community preceptors.

Appendix 1:

Family Medicine Clerkship

Telehealth Flow - Primary Care Eas

TIP: Physicians use the Doximity dialer to call patients, which displays a clinic number on the recipient's caller ID rather than your personal phone number (or 'private' that shows when you precede the dialed number with *67). Students may create Doximity accounts. It can take several days for Doximity to verify you and activate your account, at which point you may download and use the dialer.

Keep in mind that telehealth schedules are unpredictable: sometimes full ahead of time, sometimes fill at the last minute (patients don’t need any notice as they don’t have to drive anywhere), and sometimes are quite light.

Touch base with your preceptor prior to the session. The clerkship director will ask them to email you to exchange cell numbers and find a time. You will work out which patients they want you to see or at what times.|

You can find preceptors' schedules via the following(add Site specific directions here)

Call the patients you are ‘seeing’ 30 minutes prior to their scheduled appointment time. Your conversation will usually take about 20 minutes.

(If not obvious, describe how to find patient phone number)
Introduce yourself and let the patient know you are working with provider ‘X’, that you will ask them some questions to prepare for the visit, and then the provider will call them at the scheduled time
You can ask “Does this plan sound ok to you?” or something along those lines
Do a med reconciliation, confirm allergies, and ask about tobacco (if this hasn't already been done by an MA).

Take an HPI with associated ROS and briefly look at Problem List for any RELEVANT diagnoses (eg asthma in any patient with resp sx)

The problem lists are often not cleaned up so don’t feel you need to verify them, just anything that is relevant
You don’t need to write a note, unfortunately med student notes don’t count in telehealth; fortunately, the notes tend to be pretty brief and straightforward
If you have a spare 2 or 3 minutes and have gathered all the data you need to, depending on your read of the situation, don’t be afraid to do a more general “check in” with the patient, i.e. have you been able to go on any nice walks recently? What has been a source of joy for you in the last few days? Even talking about the weather for a minute or two—many people are craving just connecting with someone outside of their immediate circle about everyday life since many patients are more isolated than they are used to.

Call the preceptor after you are done talking to the patient and present your HPI and an A/P (you don’t need to read off meds/allergies/etc as the provider will be looking at the chart while you present). Don’t worry about getting the A/P all right—just explain what you are thinking like you would in clinic. If time, you and the preceptor may discuss briefly.
The preceptor will call/video the patient and ask if they can loop you back in (almost always ‘yes’) and then they will finish the visit with you on the line. You may or may not contribute to this part of the visit depending on how things flow.
The preceptor will ‘see’ the next patient while you prepare for and call the following patient (ie, if you finish a call at 2:25 pm, your preceptor may have a patient scheduled at 2:30 pm but you would be calling the 3:00 pm patient 30 minutes ahead of time, also at 2:30 pm). Remember, the schedule can be unpredictable so the flow may work differently but the preceptor should communicate this as you go – plan ahead and be ready to be flexible.
The preceptor will call you to debrief for 10-15 minutes at the end of the session.

Please feel free to give the preceptor feedback or email the clerkship director with any feedback. We are new to telehealth and even newer to teaching while we do telehealth. The more feedback we get, the better we can make it!

Appendix 2:

Family Medicine Clerkship

Preceptor Tips for Telehealth with Students

Please review the student Telehealth Flow document (appendix A)
Email the student with your cell phone number and a time to briefly review the plan for the session (ie introductions, which patients they should see, etc).

Set a time that allows 15-20 minutes of conversation with the student BEFORE the student needs to call their first patient
- For afternoon patients, this can occur mid-day
- For morning patients, this could occur the previous afternoon, early in the morning, or just ahead of your first patient with the student scheduled to call your second patient
Texting with the student during the session works well

The student presentation to you should be quite brief (~5min). If you have a light schedule or are running ahead of time, feel free to discuss their A/P at the time they present, but they will hear when you discuss with the patients and can ask questions at the end so don’t stress about this.
For Telephone visit:

Call the patient using Doximity dialer (or however you call the patient normally; it needs to be a cell phone to be able to bring another call in)
Greet the patient and ask if it is ok to bring the student the patient was just talking to back into the visit
3-way calling: (if you haven't done this before, practice with family members!)
- iPhone:
  - look at your phone once you have the patient on the line
  - on the screen with options such as ‘Speaker’, ‘Mute’, etc. tap ‘Add call’
  - dial the student's number
  - once the student picks up, tap ‘Merge Calls’
- Android:
  - look at your phone once you have the patient on the line
  - tap the 'Menu' icon
  - on the screen with options such as ‘Speaker’, ‘Mute’, etc. tap ‘Add call’
  - dial the student's number
  - once the student picks up, tap the 'Menu' icon
  - tap 'Merge'
- Remember that, once you connect with the student, the patient is on hold until you merge the calls

For Telehealth (video) visit:

Call the patient on a separate computer from the one you will be charting on OR from your cell phone if you have a land line available.
Ask permission, then call the student on the other device and put them on speaker